Date post: | 26-May-2015 |
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Managing the Client With Bowel Obstruction and Ostomy
Intestinal ObstructionSmall and large
Partial or complete
Failure of intestinal contents to move
Mechanical Causes of Intestinal Obstruction
A. Intussusceptions: The prolapse of the intestine into the lumen of the immediate adjacent part
B. Volvulus: Torsion of a loop of intestine causing an obstruction (may also have strangulation)
C. Hernia: An abnormal protrusion through the abdominal wall
Functional Causes of Bowel ObstructionIleus, paralytic ileus, adynamic)
musculature can’t propel bowel contents usually accompanied by peritonitis
Symptoms include abdominal pain and distention, vomiting and constipation. Potential complications include dehydration and shock.
Treatment : Decompression with a tube at the site of the obstruction
Small Bowell ObstructionPathophysiology
ObstructionEffluent and flatus collect above abdominal distentionDistention and fluid retention absorp & stimulate prod
of more fluids distention intraluminal press venous and art
cap press edema, congestion, necrosis, rupture
Signs and SXs of Small Bowel ObstructionCrampy abdominal pain that is wavelike and
colickyPass blood and mucus but no feces or flatusVomitingIn severe cases reverse peristalsis
Example of an x ray showing a small bowel obstruction
Large Bowel ObstructionPathophysiology
Obstruction build up of effluent & gas above site severe distention and perforationOften undramatic (unlike sbo)Strangulation and necrosis are life threatening
Adenocarcinoid tumors account for the majority of large bowel obstructions
Signs & SXs of Large Bowel ObstructionConstipation (may be the only sx for months)Alteration in the shape of stoolWeakness, anorexia and weight lossMay develop iron deficiency anemiaDistended abdomen showing the outline of
the large bowel
Treatment Options for LBOMonitor symptoms, provide sx reliefSurgical resection of bowel and formation of
ostomy (temp or permanent) if condition worsensNursing Care
Monitor for improvement, deteriorationFluid and electrolyte balancePre- & post-op care
Bowel ObstructionClinical Signs & SXs
Small Intestine Large Intestine
Onset Rapid Gradual
Vomiting Frequent & Copious Rare
Pain Colicky, cramp like, intermittent
Low grade, crampy
Bowel Movements Feces for a short duration
Absolute constipation
Abdominal Distention
Minimally increased Greatly increased
Colorectal Cancer Risk Factors (cause unknown):
Over 40 Blood in stool History of rectal polyps Family history History of inflammatory bowel disease High fat, protein, beef diet; low fiber
The third most common cause of U.S. cancer deaths
Risk factors: see Chart 38-8
Importance of screening procedures
Manifestations include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation
Treatment depends upon the stage of the disease
Patho-physiology of Colorectal CancerPredominantly adenocarcinoma (arising
from the epithelial cells of the intestineSymptoms
Right side Dull pain Melena
Left side Pain/cramping Narrowing stools Constipation Bright blood
• Rectal• Tenesmus• Pain• Felling of
incomplete evacuation
• Bloody stools
Colon Cancer
DiagnosisAbdominal and rectal examFecal occult blood testingBarium enemaColonoscopy / sigmoidoscopy with biopsy & cytology
smearsCarcinoembryonic antigen (CEA) (dx and recurrence)
Nursing Process—Assessment of the Patient With Cancer of the Colon or RectumHealth history
Fatigue and weakness
Abdominal or rectal pain
Nutritional status and dietary habits
Elimination patterns
Abdominal assessment
Characteristics of stool
Nursing DiagnosisAnxietyPainAltered nutrition, less thanHigh risk for fluid volume deficitHigh risk for infectionKnowledge deficitImpaired skin integrity
Disturbed body image
Ineffective sexuality patterns
Potential Complications of Colon or Rectal CancerIntraperitoneal infection
Complete large bowel obstruction
GI bleeding
Bowel perforation
Peritonitis, abscess, and sepsis
Distribution Of Colon Cancer
Placement of Permanent ColostomiesA. Sigmoid
Feces are solid
B. Descending Feces are
semi-mushyC. Transverse
Feces are mushy
D. Ascending Feces are
fluid
Stomas should always be beefy red
Ostomy Pouches and Accessories
Managing Nasogastric TubesFeeding vs.
DecompressionPlacement
VerificationGuidelines for
FlushingPatient Positioning
Nasogastric TubesDecompress LavageDiagnose GI motility and other disordersAdminister medications and feedingsTreat an obstructionCompress a bleeding siteAspirate gastric contents for analysis
Care of the Patient with a G-TubeCheck institution’s policy
for managementMonitor GI function and
tube insertion site at least once per shift
Assess gastric drainage for amount and characteristics each shift
Care of the Patient with an NG or G-TubeIrrigate q 4 hours.Flush a tube used for feeding with 30ml Replace irrigation equipment per protocol.Reposition as needed Clean nares, apply water soluble lubricant and retape
daily or prn. Oral hygiene Clean new abdominal tube site
Medication Administration by NG or G-TubeAssess for placement and flush with 30 ml water.When gastric suction prescribed, clamp tube for 20 minutes after
instillation of medications to allow for absorption. Avoid crushing sustained release, enteric coated products, or drugs in a
chewable or sublingual form.Administer crushed medications separately; do not mix together in
water. Flush with about 15 ml between each medication.Some medications, for example Dilantin, are rendered less potent when
given with tube feedings. For these medications, it is important to turn the feeding off for 30-45 minutes following medication administration. Check your institution’s policy for specifics.
Enteral Feeding Verify placement Verify formula, amount, and method of
administration upon initiation of feeding and minimally once per shift there after
Confirm placement Monitor for vomiting, diarrhea, changes in
aspirates, abdominal characteristics, change in bowel sounds, onset of respiratory distress, hypotension, fever or significant change in UO.
Monitor labs (especially glucose levels). Assess weight. Elevate HOB 30 degrees – when and why? Aspirate for residual